Management of Wernicke's Aphasia: A Context Based Approach - Robert C. Marshall, Ph.D., Professor, Department of Rehabilitation Sciences ...
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Management of Wernicke’s Aphasia: A Context‐
Based Approach
• Robert C. Marshall, Ph.D., Professor, Department of
Rehabilitation Sciences, University of Kentucky and
Research Consultant, University of Michigan Aphasia
ProgramWernicke’s Aphasia • Wernicke’s aphasia is associated with the German neurologist, Carl Wernicke. • Pierre Marie, the French neurologist considered Wernicke’s aphasia the only “true aphasia.” • Joseph Wepman, used the term “the talking aphasics” when referring to individuals with Wernicke’s aphasia
Causative lesions in Wernicke’s aphasia • Blockages in smaller, posterior branches of LMCA (emboli) • Damage to primary auditory cortex (41, 42), Wernicke’s area (22), second temporal and angular gyri (39, 40), white matter extension. • Damage of areas vital to language processing but not motor areas
Symptoms of Wernicke’s Aphasia Speech & Language Physical • Severe comprehension • None deficits • Individual is usually • Attention deficits independent in self care • Fluent, but severely shortly after their stroke disrupted speech • Stroke often does not result • Severe impairment of in loss of consciousness for reading and writing some individuals • Poor self monitoring
Wernicke’s Quiz There are many treatment programs and available treatment outcome studies for Wernicke’s aphasia. T/F Wernicke’s aphasia has a poorer prognosis for improvement. T/F Wernicke’s clients display less cognitive flexibility. T/F Clinician that like to control the treatment session enjoy working with the Wernicke’s client. T/F
Advantages of a Context‐Based Approach to
Management
• “Fits” with the way this type of patient is treated in the managed care
system (early discharge)
• “Helps” the patient cope with immediate demands to communicate in a
real‐life context (at home)
• “Capitalizes” on the patient’s strengths (speaking, preserved syntax,
pragmatics, mobility, speed of responsiveness)
• “Promotes” compensation (using all modalities of communication) and
provides a scaffold for caregiver education
• “Provides immediate success in communication and “sets the patient up”
for later deficit‐specific treatmentVern • Vern had a left hemisphere embolic stroke with resulting Wernicke’s aphasia. He did not lose consciousness, but his speech was severely disrupted. In fact it was so disrupted, and Vern was so upset he was taken to the police station before he was taken to a hospital.
Vern’s Hospital Course • Once in the hospital, Vern was determined to have had a stroke. He was fine physically, but he was very frustrated he could not make his needs and wants known. • He seemed to be trying to tell us something important. He become so upset with his failures he had to be placed in restraints.
Vern’s Speech Evaluation • Vern’s speech and language evaluation went poorly. He gave few meaningful responses to test items, but he never relented in trying to get an important message across to me. • Ultimately, I abandoned my attempts to test Vern, and concentrated on what he was trying to tell me.
The Birth of a Context‐Based Approach • When I stopped trying to get Vern to point to pictures and name things and just concentrated on interpreting what he was trying to tell me, I learned that the cause of his agitation was his wife’s drinking problem and the fear that she would squander their small savings. • Vern was soon discharged, but we had formed a bond that led to later treatment success. • He taught me that contextual communication was the way to go in the early stages of management with clients with Wernicke’s aphasia, and I’ve never strayed from that.
Context‐Based Management • The goal of the context‐based approach is to improve listening comprehension and information exchange in authentic communicative contexts.
Authentic Communication
Contexts ?
• Topics/issues the patient wants, needs, or can
communicate about; problems the patient
wants to solve
• Vern: Fears and concerns over $
• Marie: Going home
• Pat: Child custody
• Celia: Tuning in to the right Bible passageCreating Communicative Contexts All patients are not like Vern. Sometimes the clinician has to create a context. She can do this by connecting to the patient’s personal interests: • Reviewing medical chart • Observing • Ask the family about the patient’s pre‐morbid interests • Biographies
For Example
“Cub Fan”
• Humor/sarcasm: “They blew it again”
• Emotion: “Could this really be the year?”
• Shared knowledge: “I’m a big Cub fan too.”
• Available props: “What’s going on with the
Cub’s today?”Strengthening the Contextual Connection • Written information detailing the topic, key words, or other information • Facial expression, gesture, body position, tone of voice • Relevant pictures • Personal artifacts of the patient
Once Connected Capitalize on: Minimize need for: • Ability to converse (fluency) • Bottom up and off line • Preserved syntax (ability to comprehension shift tenses) • Retrieval of specific words • Preserved pragmatics • Repetition or to respond to (humor, nuance, sarcasm) cues • Speed of responsiveness
Support for Context‐Based
Treatment
• Several clinical papers in your reference list provide
therapeutic suggestions that are relevant to a context‐based
approach.
• From these come a number of suggestions for enhancing
comprehension and improving information exchange for the
patient with Wernicke’s aphasia in the early post onset
period.Comprehension comes first: Find the hole in the
screen
Imagine you have a wire mesh • Context primes the client for
screen and you throw gooey, listening
sticky mud at the screen. • Through trial and error, and
Some holes in the mesh will be by learning from past
filled with mud; others will be experience, the clinician finds
open. a hole in the screen.
For the client to comprehend, • Once the client comprehends
you have to hit an open hole a message, she moves on
from there by continuing the
conversation.Suggestions from the Auditory Comprehension Literature on
Improving Contextual Comprehension
• Highlight main ideas
• Emphatic stress to important words
• Use direct wording
• Use repetition and paraphrasing
• Speak a little slower and get the client’s
attention
• Cohesive tiesMaintaining the Context • Reinforce and encourage the client to ask for repeats; ask for repeats yourself • Verify and rephrase what the client has said; ask rhetorical questions • Clearly alert the client to topic switches and re‐orient to the topic • Give the client a listening break
Demonstrate How to Maximize
Comprehension
In a contextual situation where the topic is
known to all the therapist can:
• Demonstrate how to talk to the client to
maximize comprehension
• Reveal the client’s competence
• Family members and staff tune in better to
topics of mutual interestStop versus Go Strategies • Originally, it was believed that the best way to work with the Wernicke’s client was to “stop the patient form talking and have him/her listen and tune into their errors. • Martin (1981 a, b) questioned stopping the best thing the patient did and offered an alternative “go” strategy
Implementing a “Go” Strategy • Identify a topic of interest to the client that you know something about and let the patient teach you about it • Because you have apriori knowledge of the topic, you can be a good interpreter of the client’s defective utterances
Breaking the Cycle • Paraphrase and re‐phrase the client’s defective utterances so that they are “fed” back to the client as a good model • This breaks a garbage out garbage in cycle and maintains communication and information exchange • It provide the client with success
Taking Your Cue from the Client • Filling in the blanks and providing the client with the missing word in a face‐saving manner • Encouraging the client to keep trying • Forgetting about the word finding problem and moving on because the client has conveyed the meaning • Admit if you don’t get it – move on in a face‐saving manner
Increase Degrees of Freedom • Increase the number of options for conveying a specific thought (related words, descriptions, direct reference to items) • Dramatically reduce the use of “Wh” questions • Ask open ended questions – make open ended statements for the client to pick up on
Compensations • Reinforcing the client for being cognitively flexible and successfully using drawing, writing, gesture, and pointing to convey information • Discouraging the use of ineffective compensations, by filling in the missing word for the client and telling him/her when something does not help
Self‐correction • Reinforce error awareness and any effort to self correct whether successful or unsuccessful
Variability • Wernicke’s clients are unduly concerned that their ability to communicate specifics varies from day‐to‐day • Sometimes counseling is needed
Successes • Summarize things for the client when information has been successfully transmitted • The immediate success in sending and understanding messages prepares the client for later deficit‐specific work
Mary • 65 year old woman had a left hemisphere ischemic stroke while at home. • No LOC; no physical deficits; complete loss ability to communicate • Mary realized she could not drive; she walked two miles to a brother’s house for help
Mary’s Story • Wernicke’s aphasia – severe • Early rehabilitation unsuccessful • Mary living at home alone, but successfully • Mary enrolled in University clinic • Unresponsive to deficit‐specific treatment • Responsive to context‐based treatment
Functional Tests Direct Indirect • CADL‐II • ASHA FACS • Everyday language test • FAQ‐A • Aphasia Functional • CETI Language Assessment • Oxenham Questionnaire • Inpatient Functional Assessment Interview
Summary
No Yes
Drill Personally relevant material
Repetition Giving the client options
Tasks requiring bottom up Increasing degrees of freedom
processing for word choices
Cues/prompts Taking responsibility for
Acontextual material comprehension and
correctionAtmosphere of Delight • Aphasia represents a problem accessing a learned code. • The person with aphasia is competent • Language was learned in an “atmosphere of delight” which was always a context • It makes sense to restore it in a similar venue
References
Cochrane, M. (1983). Language and the atmosphere of delight. In Winitz, H. (Ed.). Treating Language Disorders:
for Clinicians by Clinicians, (pp. 143‐162). Baltimore: University Park Press.
Golper, LA, Rau, MT (1983). Systematic analysis of cueing strategies in aphasia: taking your cue from the
patient. In Brookshire R (ed.), Clinical aphasiology: Conference proceedings, http://aphasiology.pitt.edu
Marshall, RC (2008). Early management of Wernicke’s aphasia: A context‐based approach. In Chapey R (ed.),
Language interventions strategies in aphasia and related neurogenic communication disorders (5th ed.),
507‐529, Baltimore: Lippincott, Williams & Wilkins.
Marshall, R. C. (1983). Communication styles of fluent aphasic clients. In Winitz, H. (Ed.). Treating Language
Disorders: for Clinicians by Clinicians, (pp. 146‐180. Baltimore: University Park Press.References
Martin, AD (1981a). Therapy with the jargonaphasic. In Brown J (ed.), Jargonaphasia, (pp. 305‐326). New York:
Academic Press.
Martin, AD (1981b). An examination of Wepman’s thought centered therapy. In In Chapey R (ed.), Language
interventions strategies in aphasia and related neurogenic communication disorders (pp.141‐154,
Baltimore: Williams & Wilkins.
Wepman, JM (1972). Aphasia therapy: a new look. Journal of Speech and Hearing Disorders, 37, 203‐214.You can also read
